Provider Demographics
NPI:1508512104
Name:WALKER, CARLY ROSE (LLMSW)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ROSE
Last Name:WALKER
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 FOUNTAIN ST NE APT A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3530
Mailing Address - Country:US
Mailing Address - Phone:616-828-3256
Mailing Address - Fax:
Practice Address - Street 1:4572 S HAGADORN RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5385
Practice Address - Country:US
Practice Address - Phone:616-287-4986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511103411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical